Advanced Imaging Techniques in Skull Base Osteomyelitis Due to Malignant Otitis Externa

Skull base osteomyelitis: HBO as a therapeutic concept Effects on clinical and radiological results

INTRODUCTION

Skull base osteomyelitis is a rare but potentially life-threatening disease. It usually occurs as a complication of severe otitis externa or infection in the nasopharynx, often in immunocompromised patients. The therapeutic strategy is complex, patient-specific and requires interdisciplinary cooperation.

MATERIAL AND METHOD

A retrospective evaluation of all patients with skull base osteomyelitis at the Department of Otorhinolaryngology of the University Hospital Duesseldorf from 2006 to 2023 was carried out. It was investigated which factors, in addition to treatment regimens (antibiotic therapy with i.v./oral antibiotics, surgical debridement and HBO therapy) have an influence on the clinical, laboratory and morphological outcome of the patients.

RESULTS

A total of 42 patients who received interdisciplinary treatment in our clinic were included in the study, of whom 71.4% were male and 28.6% female. The tissue samples showed an inflammatory process, with detection of Pseudomonas aeruginosa in 68.4% of patients. A total of 61.9% of patients presented cranial nerve deficits, most frequently facial nerve palsy. A total of 66.7% of patients received HBO therapy. Of these, n = 20/23 patients (87%) with HBO improved and achieved regression in the follow-up imaging. Known patient-specific factors were confirmed and HBO was emphasized as an important component of the multimodal therapy concept. HBO appears to be justified and should continue to be included in the treatment regimen in the future. For this reason, patients with SBO should be sent to a center that offers HBO therapy.

Deciding treatment end point in necrotizing otitis externa: validation of a standardized clinical response assessment strategy with positron emission tomography findings

OBJECTIVES

Primary: To explore criteria for treatment endpoint in NOE. Secondary: To study correlation of inflammatory markers, Erythrocyte sedimentation Rate (ESR) and C-reactive protein (CRP) with disease status.

METHODS

Prospective cohort study conducted in a tertiary care hospital over two years (2021-2023) consisted 28 patients with NOE. Treatment culmination point was decided based on symptoms control and correlated with PET-scan findings. Clinical response was analysed with respect to the serum inflammatory markers and PET Scan findings.

RESULTS

There was fair degree of agreement between clinical resolution and resolution of findings on PET scan (kappa coefficient - 0.76 [95% CI; 0.40,1.00]). Inflammatory markers showed statistically significant decline with clinical resolution but failed to return to normal.

CONCLUSION

Decision to terminate treatment of NOE can be reliably made on clinical grounds in patients remaining asymptomatic for three weeks. Resolution of inflammation on PET scan is in congruity with the clinical remission .

Skull Base Rhabdomyosarcoma Mimicking Osteomyelitis in a Pediatric Patient

Rhabdomyosarcoma (RMS) is a rare malignant tumor, affecting 4.58 per 1 million children, with approximately 35% occurring in the head and neck. Skull base RMS commonly presents at advanced stages and delays diagnosis due to its overlapping features with other skull base pathology, and difficulty accessing the lesion for biopsy. This case illustrates these challenges in skull base RMS mimicking osteomyelitis of the petrous apex. Case: A 6-year-old immunocompetent female, with a history of two acute otitis media episodes, presented with a 3-week history of sixth cranial nerve palsy and sudden-onset complete seventh cranial nerve palsy. She did not have pain or otorrhea. Computed tomography (CT) and magnetic resonance imaging revealed a 1.3 cm left petrous apex enhancing lesion with extension into the mastoid and clivus with surrounding bony and soft tissue destruction. A nuclear medicine scan (Technetium-99m followed by gallium) demonstrated avid uptake in the left petrous apex. The working diagnosis was skull base osteomyelitis, for which the patient received 2.5 weeks of antibiotics. After failing to improve, repeat imaging showed significant progression of the disease and extension into the nasopharynx and sphenoid sinus. An endoscopic trans-sphenoidal biopsy was performed with pathology consistent with RMS. CT chest revealed lung metastases. The patient partially responded to chemotherapy with vincristine, actinomycin-D, and cyclophosphamide alternating with vincristine and irinotecan. During week 13 of chemotherapy, she received concomitant proton therapy to a total dose of 5040 cGyRBE. Five months after diagnosis, she developed leptomeningeal spread, which was further complicated by meningitis, and passed away.

Skull base osteomyelitis due to bilateral acute otitis media: Case report and literature review

Skull base osteomyelitis is a rare and serious condition that primarily affects immunocompromised individuals and can be life threatening if not treated promptly. It can have various origins, with the most common being an extension of necrotizing external otitis. It is difficult to diagnose due to a wide array of clinical presentations. Imaging plays an important role in the diagnosis, identification of the possible source of infection, the extent of the disease, the pattern of spread and identification of associated complications. Early diagnosis is crucial to promptly initiate appropriate treatment. We report here a rare case of a 68-year-old patient presenting with skull base osteomyelitis resulting from bilateral otitis media, which is a rare condition.

Diagnostic criteria and core outcome set development for necrotising otitis externa: the COSNOE Delphi consensus study

OBJECTIVE

Evidence for necrotising otitis externa (NOE) diagnosis and management is limited, and outcome reporting is heterogeneous. International best practice guidelines were used to develop consensus diagnostic criteria and a core outcome set (COS).

METHODS

The study was pre-registered on the Core Outcome Measures in Effectiveness Trials (COMET) database. Systematic literature review identified candidate items. Patient-centred items were identified via a qualitative study. Items and their definitions were refined by multidisciplinary stakeholders in a two-round Delphi exercise and subsequent consensus meeting.

RESULTS

The final COS incorporates 36 items within 12 themes: Signs and symptoms; Pain; Advanced Disease Indicators; Complications; Survival; Antibiotic regimes and side effects; Patient comorbidities; Non-antibiotic treatments; Patient compliance; Duration and cessation of treatment; Relapse and readmission; Multidisciplinary team management.Consensus diagnostic criteria include 12 items within 6 themes: Signs and symptoms (oedema, otorrhoea, granulation); Pain (otalgia, nocturnal otalgia); Investigations (microbiology [does not have to be positive], histology [malignancy excluded], positive CT and MRI); Persistent symptoms despite local and/or systemic treatment for at least two weeks; At least one risk factor for impaired immune response; Indicators of advanced disease (not obligatory but mut be reported when present at diagnosis). Stakeholders were unanimous that there is no role for secondary, graded, or optional diagnostic items. The consensus meeting identified themes for future research.

CONCLUSION

The adoption of consensus-defined diagnostic criteria and COS facilitates standardised research reporting and robust data synthesis. Inclusion of patient and professional perspectives ensures best practice stakeholder engagement.

Clival Osteomyelitis in an Adult Patient: A Case Report

Clival osteomyelitis is an uncommon skull base infection that mostly affects elderly diabetics and is frequently caused by malignant otitis externa or paranasal sinus infections. It manifests as severe otalgia, fever, auditory fullness, and purulent otorrhea. Clinical history, physical examination, test data, radiographic findings, and pathogen identification all contribute to a diagnosis. Treatment consists of extended intravenous broad-spectrum antibiotics, with severe cases necessitating surgical debridement. We present a case of a 20-year-old girl with bilateral ear discharge, nasal blockage, and purulent rhinorrhea, as well as a dull neck ache increased by extension. An MRI revealed osteomyelitis in the clivus and right atlanto-occipital joint. The clival abscess was drained transnasally using endoscopic techniques. Microbiological tests revealed Streptococcus intermedius. The post-operative recovery was uneventful, with extended antibiotic therapy. Early identification and treatment are critical for preventing serious consequences, as illustrated in this case, where surgical and antibiotic care improves patient outcomes.

Role of follow-up gallium scintigraphy in the evaluation of malignant external otitis (skull base osteomyelitis): A case report

Malignant otitis externa (skull base osteomyelitis) can be fatal and long-term antibiotic therapy is recommended. Despite being potentially fatal, this infection causes minor changes in inflammatory biomarkers (white blood cell count and C-reactive protein levels) upon blood testing. Computed tomography and magnetic resonance imaging changes persist over a long period. Therefore, it is difficult to determine the optimal time for the discontinuation of antibiotics. We present a 77-year-old male whose medical history included type 2 diabetes mellitus who suffered from chronic otitis media with Pseudomonas aeruginosa infection. His condition did not improve with proper treatment, and imaging revealed malignant otitis media. Intravenous cefepime treatment was administered. Antibiotic treatment was de-escalated to oral levofloxacin treatment after Gallium-67 scintigraphy showed less accumulation after 6 weeks of Cefepime administration; accumulation almost disappeared after 1 year. In this report, we describe the usefulness of gallium scintigraphy in the evaluation of malignant otitis externa.

Epidemiology and risk factors for extension of necrotizing otitis externa

PURPOSE

Necrotizing otitis externa (OEN) is an aggressive and morbid infection of the external acoustic meatus. What are the risk factors for OEN extension?

METHODS

French monocentric retrospective study (2004-2021), including patients with OEN defined by the association of an inflamed EAM, a positive nuclear imaging, the presence of a bacteriological sample and the failure of a well-followed local and/or general antibiotic treatment. OEN was extensive if it was associated with vascular or neurological deficits, if nuclear imaging fixation and/or bone lysis extended beyond the tympanic bone.

RESULTS

Our population (n = 39) was male (74%), type 2 diabetic (72%), aged 75.2 years and pseudomonas aeruginosa was found in 88% of cases. Complications for 43% of patients were extensive fixation on nuclear imaging, for 21% of them the presence of extensive bone lysis, for 13% the appearance of facial palsy, for 5.3% the presence hypoglossal nerve palsy and for 2.5% the presence of thrombophlebitis or other nerves palsies. 59% of our population had extensive OEN. The diagnosis of the extensive OEN was made 22 days later (p = 0.04). The clinical presentation was falsely reassuring due to easier identification of the tympanic membrane (70% vs 46%, p = 0.17) but associated with periauricular oedema (42% vs 0%), bone exposure (16% vs 0%) and a temporomandibular joint pain (41% vs 12%).

CONCLUSION

Delayed treatment of OEN, identification of clinical bone lysis, especially when the tympanic membrane is easily visualized, and the presence of unbalanced diabetes are potential risk factors for extension of OEN.

Exploring the OTITIS Research Landscape Through a Scientometric Approach

Otitis media is a common health problem affecting people of all ages and significantly impacting public health and healthcare costs. Otitis media, a type of middle ear disease, is one of the most common types. This scientometric study aimed to provide an overview of the knowledge domain in otitis media research. Documents were retrieved from the Web of Science database. A scientometric study was then performed on a sample of 27,213 documents. This study found that research on otitis media has increased significantly in recent years, with an annual growth rate of 4.58%. The average age of the documents analyzed was 18 years, with an average of 21.88 citations and an average of 4.58 authors. The United States, the United Kingdom, and Japan ranked first to third in terms of number of publications. Still, the United States, China, and Sweden were in a better position in terms of impact on the research network. Co-occurrence word analysis showed that significant attention was given to topics such as chronic inflammation in autism, acute inflammation in otitis media, and increased fluid in the middle ear. This study highlights the need to prioritize and focus attention on otitis, particularly otitis media, due to its prevalence and impact on public health. The use of scientometric software, such as Biblioshiny and CiteSpace, provides a valuable means of assessing research trends and identifying important areas for future study in the field of knowledge.

Imaging spectrum and complications of otogenic infections: insights into delayed diagnosis

Skull base osteomyelitis (SBO) is a late manifestation of complicated otogenic infections that presents a diagnostic challenge. Delayed or missed diagnoses lead to high morbidity and mortality and can be attributed to non-specific symptoms, subtle early radiologic findings, radiologic mimicry of nasopharyngeal carcinoma (NPC), and under-recognition from clinician and radiologists. This pictorial review aims to emphasize on early imaging recognition and distinction between SBO and NPC.

The diagnostic conundrum in necrotizing otitis externa

Necrotizing otitis externa (NOE) is an aggressive and fast-evolving infection of the external auditory canal. Late diagnoses and untreated cases can lead to severe, even fatal consequences and so early diagnosis and treatment are paramount. NOE is a notoriously challenging diagnosis to make. It is therefore important to understand what diagnostic modalities are available and how otolaryngologists can use them to accurately treat such an aggressive disease. This review aims to evaluate the different diagnostic options available in NOE and discuss their advantages and limitations, thus, providing an up-to-date picture of the multimodal approach required in the diagnosis of this disease.

Necrotizing external otitis: diagnostic clues in the emergency department

PURPOSE

The assessment of necrotizing external otitis requires a high index of suspicion by the attending physician. The purpose of the study is to determine the accuracy of parameters available at the Emergency Department for the diagnosis of this pathology.

METHODS

Retrospective diagnostic accuracy study. Patients consulting at the Emergency Department for longstanding ear swelling, severe otalgia, and failure to respond to topical treatment were included. Otoscopy, physical examination, CT appearance, and analytical results were tested for the diagnosis of necrotizing external otitis, using nuclear imaging as gold standard. Sensitivity, specificity, likelihood ratios and ROC curves were calculated.

RESULTS

24 patients were included; 13 cases were necrotizing external otitis, and 11 cases were other external ear pathologies. Erythrocyte sedimentation rate and C-reactive protein levels were significantly associated with necrotizing external otitis (AUC 0.92 p < 0.001, and 0.8 p < 0.001). Positive likelihood ratios were 10.15 for values of erythrocyte sedimentation rate over 26 mm/h, and 8.25 for C-reactive protein levels over 10 mg/L. Negative likelihood ratios were 0.08 and 0.28, respectively. These results were significant. The rest of clinical and radiological parameters were less accurate.

CONCLUSIONS

Erythrocyte sedimentation rate and C-reactive protein are useful parameters in the evaluation of a case of longstanding otitis with clinical suspicion of necrotizing external otitis. If any of them is elevated, the probability of suffering this condition is significantly increased. If they are within normal ranges, an alternative diagnosis should be sought.

Skull base infections, their complications, and management

OBJECTIVE

Our review aims to summarize the current literature on skull base infections (SBIs) and retrospectively analyze any such cases encountered at our institution.

DESIGN

A literature search was conducted using online databases PubMed, MEDLINE, and ResearchGate with the terms "skull base osteomyelitis," "temporal bone osteomyelitis," "skull base infections," "necrotizing otitis media," and "SBO". References from the resulting manuscripts were reviewed for relevant articles. A search of our electronic health records using the same key terms was also performed to identify patients with a tissue biopsy-confirmed diagnosis of skull base infections. Patients with an indeterminate diagnosis or inaccessible/poor imaging were excluded.

SETTING

A level one trauma and major tertiary academic medical center.

PARTICIPANTS

All patients treated at the University of California Davis Health System with a confirmed diagnosis of skull base infections from January 2005 to November 2020.

MAIN OUTCOME MEASURES

Imaging results, symptoms, treatment, morbidity, and mortality.

RESULTS

Our literature search yielded 59 articles ranging from 1982 to 2021. A retrospective search of our electronic health records identified two cases of skull base infections.

CONCLUSION

Skull base infections have no pathognomonic findings. A multimodal approach with computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine is necessary to characterize the disease process in addition to a biopsy for definitive diagnosis. Other diagnoses can mimic SBI on imaging, such as nasopharyngeal carcinoma and inflammatory pseudotumor. Culture-guided antimicrobial treatment and surgery are mainstay therapies. Other adjuvant strategies currently lack the robust evidence necessary to characterize their risks and benefits.

68 Ga-Citrate PET/CT Imaging in the Diagnosis of Skull Base Osteomyelitis and Its Usefulness in the Assessment of Treatment Response

PURPOSE

68 Ga-citrate PET/CT imaging in the diagnosis of skull base osteomyelitis (SBO) and its usefulness in the assessment of treatment response.

METHODS

Eighteen patients underwent 68 Ga-citrate PET/CT scans for suspected SBO for diagnosis/assessment of treatment response.

RESULTS

Of 18 patients, 16 patients had a positive study for SBO, and 2 patients had a negative study. Scan findings were correlated with clinical, biochemical, microbiological, and radiological parameters.

CONCLUSION

68 Ga-citrate PET/CT is a promising tool in the diagnosis and management of skull base osteomyelitis.

State of the art in the diagnostic evaluation of osteomyelitis: exploring the role of advanced MRI sequences-a narrative review

Background and Objective

Osteomyelitis, a severe bone infection caused mainly by pyogenic organisms, poses diagnostic challenges due to its non-specific magnetic resonance imaging (MRI) manifestations. Conventional MRI, though the imaging modality of choice, often exhibits signal abnormalities with overlapping differential diagnoses, potentially leading to overestimation of infection extent and duration. To address these limitations, advanced MRI sequences, including dynamic contrast-enhanced (DCE) MRI, 1H magnetic resonance spectroscopy (MRS), diffusion-weighted imaging (DWI), and Dixon techniques have emerged as promising alternatives. This narrative review explores the potential role of these sequences in aiding the differential diagnosis of osteomyelitis.

Methods

We used the PubMed database to search for relevant articles using the MeSH keywords: (osteomyelitis) AND (advanced MRI sequences) and we manually selected the most suitable studies to include in our review. Articles outside of original studies were also included. Only records in English or French were considered.

Key Content and Findings

In particular, DWI is useful for characterizing fluid collections, distinguishing bone infarcts, and bacterial skull base osteomyelitis from neoplastic lesions. Moreover, DWI assists in differentiating diabetic foot osteomyelitis (DFO) from Charcot neuro-osteoarthropathy, facilitates the diagnosis of pediatric acute osteoarticular infections, and aids in distinguishing osteomyelitis from Modic I degenerative changes. Additionally, DWI proves valuable in monitoring spinal infections and distinguishing pedal osteomyelitis from other conditions, even in patients with renal impairment. DCE-MRI enhances MRI specificity by assessing contrast uptake over time, providing valuable insights into inflammatory microenvironments. It aids in detecting DFO, differentiating it from acute Charcot arthropathy, and distinguishing osteomyelitis from neuropathic arthropathy. Moreover, DCE-MRI shows potential in assessing response to antibiotic therapy in spinal infections. Dixon acquisition improves image quality and facilitates the detection of bone marrow abnormalities, aiding in the differentiation of diabetic foot from osteomyelitis. It also assists in distinguishing osteomyelitis from neuropathic arthropathy and provides valuable information in evaluating the diabetic foot. Proton MR spectroscopy, a well-established modality, offers metabolic information that can differentiate malignant from benign lesions.

Conclusions

The role of advanced MRI techniques in evaluating osteomyelitis remains to be fully defined, and further research is required to explore its potential utility in this context. In conclusion, the incorporation of advanced MRI sequences has shown promise in improving the differential diagnosis of osteomyelitis. Future investigations exploring combinations of these techniques and their clinical applications hold significant potential to enhance diagnostic accuracy and patient outcomes.

Extensive Base of Skull Osteomyelitis: Why Does It Still Occur?

Skull base osteomyelitis (SBO) is a rare yet serious intratemporal infection that often masquerades as a skull base malignancy. It is most common in diabetic and immunocompromised patients. We present a case of an elderly diabetic patient with end-stage renal disease with progressive malignant otitis externa. The disease progressed to involve the base of the skull, causing multiple cranial neuropathies. Early initiation of intravenous (IV) antibiotics, along with supportive treatment, may improve the long-term prognosis of the disease. This case highlights the importance of keeping a high index of diagnostic suspicion for SBO in patients with risk factors. Early diagnosis and prompt treatment can drastically decrease morbidity and mortality due to SBO.

Management and Outcomes of Necrotizing Otitis Externa: A Retrospective Cohort Study in a Tertiary Referral Center

Objectives

Necrotizing otitis externa (NOE) is a rare infection of the ear that causes osteomyelitis. We aimed to evaluate treatment outcomes and the role of imaging in diagnosing and monitoring disease resolution in a single-center study of patients with NOE.

Methods

In this retrospective cohort study, patients with NOE who were diagnosed and treated in a tertiary otology center in Utrecht, The Netherlands, between January 1, 2013 and August 1, 2022, were included. Data were retrieved from the medical records on demographics, symptoms, physical and diagnostic findings, type and duration of treatment, and course of disease.

Results

A total of 24 cases were included. Patients were often elderly (mean age = 75 years) and diabetic (88%). Pseudomonas aeruginosa was the most commonly found microorganism (63%). Twenty-two cases (92%) received intravenous antibiotic treatment, and 7 cases (29%) received additional systemic antifungal treatment. The mean duration of systemic treatment was 29 weeks. In 20 out of 22 cases (91%), imaging was used to determine the end point of treatment. None of the cases with a total resolution of disease activity (n = 5) on 18F-fluorodeoxyglucose-positron emission tomography-computed tomography imaging at the time of cessation of therapy showed clinical relapse, compared with 1 out of 4 cases on gallium single-photon emission computerized tomography.

Conclusion

Based on the experience from our center, we demonstrated that patients with NOE can successfully be treated with prolonged systemic treatment. Molecular imaging is reasonably successful for disease evaluation and decision-making on the eradication of disease.

Clinico-Radiological Evaluation for Longitudinal Assessment in Central Skull Base Osteomyelitis: Proposal of Novel Scoring System

This study aims to evaluate clinical, radiological and laboratory parameters for longitudinal assessment and prognostication in central skull base osteomyelitis (CSBO). Novel radiological score and cranial nerve assessment score (CNAS) have been proposed and analysed along with pain score (VAS), ESR, CRP, WBC count, and HbA1c for utility in disease-monitoring and predicting outcome in CSBO. CSBO cases managed in a tertiary care centre from January 2018 to November 2020, with a minimum follow-up of 6 months were included. The parameters were recorded at presentation, 3-month, 6-month postoperative follow-up, and at completion of therapy, for statistical analysis. Significant positive correlation was found amongst pain score, CNAS, radiological score, ESR, and CRP at different timelines. On longitudinal assessment, there was a statistically significant reduction in above-mentioned parameters, in the cases who recovered. Those with initial radiological score < 30, pain score ≤ 7, and CNAS < 10 showed early clinical improvement, required shorter duration of antimicrobial therapy, and exhibited higher probability of becoming disease-free at an earlier time, compared to those presenting with higher scores. We propose the use of pain score, a novel cranial nerve assessment score, and a novel radiological score for longitudinal assessment in CSBO. The trend in these parameters along with ESR and CRP are useful to monitor the disease process. The initial assessment scores can predict duration of antimicrobial therapy and probability of early recovery. WBC count and HbA1c were neither useful for disease-monitoring nor predicting outcome.

[Research progress of necrotizing otitis externa]

Necrotizing otitis externa is a progressive infectious disease involving the external auditory canal and even the skull base, which can lead to serious complications and even death if not treated in time. In this paper, the latest advances in etiology, pathogenesis, clinical manifestations, diagnosis and treatment were reviewed based on previous literature, providing reference for clinical diagnosis, treatment and future research.

Necrotizing Otitis Externa: A Proposal for Diagnostic and Therapeutic Approach

Introduction  Necrotizing otitis externa has a high impact on the quality of life of patients and has shown a significant increase in its incidence in recent years. There has been a change in the profile of affected patients and a lack of consensus on the management of these patients. Objective  To develop a practical and effective care protocol to standardize the diagnostic and therapeutic management of necrotizing otitis externa. Methods  A retrospective cohort study of necrotizing otitis externa patients between January 2015 and December 2020. Results  There were 34 patients with two bilateral cases, totaling 36 ears. The mean age was 68.5, with a higher prevalence of males (76%). Diabetes was present in 97% of the samples. The involvement of cranial pairs was identified in 35% of the sample. Pseudomonas aeruginosa was the most frequent pathogen isolated, found in 50% of the cases. Among the cultures with bacterial agents isolated, 35% showed resistance to ciprofloxacin. The most frequent exam was computed tomography (94%). Hospital admission was indicated for 31 patients (91%), and ceftazidime was the most prescribed drug (35.5%). There were 11 recurrences (32%), and 12 patients (35%) had complications during treatment. Among the unfavorable outcomes, 12% persisted with some degree of peripheral facial paralysis, 6% maintained dysphagia, and 9% died of the disease. Conclusions  The present study developed a diagnostic and therapeutic protocol for the effective management of necrotizing otitis externa. This protocol is a dynamic tool and should be revised and updated as new demands emerge during its implementation.

Dynamic contrast-enhanced MRI parameters and apparent diffusion coefficient as treatment response markers of skull base osteomyelitis: a preliminary study

Purpose

Currently, there is no definitive consensus on the optimal imaging modality for determining the treatment response in patients with skull base osteomyelitis (SBO). This study aimed to investigate the utility of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parameters and apparent diffusion coefficient (ADC) as treatment response markers of SBO.

Material and methods

This study included 6 patients with SBO, who underwent both pre- and post-treatment DCE-MRI and diffusion-weighted imaging (DWI). Quantitative DCE-MRI parameters and ADC of the region-of-interest were analysed. These normalized parameters were calculated by dividing the region-of-interest by the reference region. The Wilcoxon signed rank test was used to compare these parameters between pre- and post-treatment periods.

Results

The normalized fraction of the extravascular extracellular space (Ve) and ADC of the post-treatment status of SBO was significantly lower than those of pre-treatment measures (p = 0.03). The normalized fraction of blood plasma (Vp), normalized rate of transfer from the blood plasma into the extravascular extracellular space (Ktrans), and normalized backflow leakage of material from the extravascular extracellular space into the blood plasma (Kep) demonstrated no significant differences between pre- and post-treatment.

Conclusions

DCE-MRI parameters Ve and ADC demonstrated a significant reduction when comparing measures across the pre- and post-treatment periods. These parameters may potentially serve as a valuable surrogate treatment response marker for SBO activity.

Atypical Skull-Base Osteomyelitis: Comprehensive Review and Multidisciplinary Management Viewpoints

Atypical skull-base osteomyelitis is a rare but fatal disease that usually involves infection of the ethmoid, sphenoid, occipital, or temporal bones that form the skull base. Unlike typical (so-called otogenic), atypical skull-base osteomyelitis has no otogenic cause. Instead, some authors call atypical skull-base osteomyelitis sinonasal, since the infection most often originates from the nose and paranasal sinuses. Diagnosing and treating this disease is challenging. To assist in managing atypical skull-base osteomyelitis, a review of the most recent literature, with patient cases and multidisciplinary perspectives from otolaryngologists, neurosurgeons, radiologists, infectious disease specialists, pathologists, and clinical microbiologists, is provided in this paper.

Observational Study on Clinical Features and Management of Skull Base Osteomyelitis in Hospitalised Patients at a Tertiary Care Hospital

1. To study the various clinical presentations, microbiological and radiological profiles in patients of skull base osteomyelitis, to know about the underlying comorbidities or immunocompromised status and its relation to the disease and its management. 2. To study the effect of long term intravenous antimicrobial therapy with respect to clinical outcomes and radiological improvement and to study the long term outcomes of the treatment. This is an observational prospective and retrospective study. Thirty adult patients who were diagnosed with skull base osteomyelitis by clinical/microbiological and or radiological features were treated with long term intravenous antibiotics according to pus culture and s for 6-8 weeks and they were followed up for 6 months. Clinical improvement in symptoms and signs, radiological imaging features and pain score were assessed after 3 and 6 months. We noticed in our study that skull base osteomyelitis are more common in older patients with male predominance. Presenting symptoms include ear discharge, otalgia, hearing, cranial nerve palsy. Immunocompromised state, mainly Diabetes mellitus is closely associated with skull base osteomyelitis. Majority of patients showed Pseudomonas related species on pus culture and sensitivity. All the patients showed temporal bone involvement in CT and MRI. Other bones involved were shenoid, clivus and occipital bone. Majority showed good clinical response to intravenous ceftazidime, combination of piperacillin and tazobactum, followed by combination of piptaz and Ciprofloxacin. Treatment duration was 6-8 weeks. All patients showed clinical improvement in symptoms and relief in pain after 3 and 6 months. Skull base osteomyelitis is a rare condition, most commonly seen in elderly patients with diabetes mellitus and or other immunocompromised condition. Pseudomonas related species are the major causes of skull base osteomyelitis. Long term pus culture and sensitivity bases intravenous antibiotic therapy is the main stay of treatment.

Advanced imaging of head and neck infections

When head and neck infection is suspected, appropriate imaging contributes to treatment decisions and prognosis. While contrast-enhanced CT is the standard imaging modality for evaluating head and neck infections, MRI can better characterize the skull base, intracranial involvement, and osteomyelitis, implying that these are complementary techniques for a comprehensive assessment. Both CT and MRI are useful in the evaluation of abscesses and thrombophlebitis, while MRI is especially useful in the evaluation of intracranial inflammatory spread/abscess formation, differentiation of abscess from other conditions, evaluation of the presence and activity of inflammation and osteomyelitis, evaluation of mastoid extension in middle ear cholesteatoma, and evaluation of facial neuritis and labyrinthitis. Apparent diffusion coefficient derived from diffusion-weighted imaging is useful for differential diagnosis and treatment response of head and neck infections in various anatomical sites. Dynamic contrast-enhanced MRI perfusion may be useful in assessing the activity of skull base osteomyelitis. MR bone imaging may be of additional value in evaluating bony structures of the skull base and jaw. Dual-energy CT is helpful in reducing metal artifacts, evaluating deep neck abscess, and detecting salivary stones. Subtraction CT techniques are used to detect progressive bone-destructive changes and to reduce dental amalgam artifacts. This article provides a region-based approach to the imaging evaluation of head and neck infections, using both conventional and advanced imaging techniques.

UK consensus definitions for necrotising otitis externa: a Delphi study

OBJECTIVE

To establish consensus definitions for necrotising otitis externa (NOE) to facilitate the diagnosis and exclusion of NOE in clinical practice and expedite future high-quality study of this neglected condition.

DESIGN

The work comprised of a systematic review of the literature, five iterative rounds of consultation via a Delphi process and open discussion within the collaborative. An expert panel analysed the results to produce the final outputs which were shared with and endorsed by national specialty bodies.

SETTING

Secondary care in the UK.

PARTICIPANTS

UK clinical specialists practising in infection, ear nose and throat (ENT) surgery or radiology.

MAIN OUTCOME MEASURES

Definitions and statements meeting the following criteria were accepted: (a) minimum of 70% of respondents in agreement or strong agreement with a definition/statement AND (b) <15% of respondents in disagreement or strong disagreement with a definition/statement.

RESULTS

Seventy-four UK clinicians specialising in ENT, Infection and Radiology with a special interest in NOE took part in the work which was undertaken between 2019 and 2021. The minimum response rate for a Round was 76%. Consensus criteria for all proposed case definitions, outcome definitions and consensus statements were met in the fifth round.

CONCLUSIONS

This work distills the clinical opinion of a large group of multidisciplinary specialists from across the UK to create practical definitions and statements to support clinical practice and research for NOE. This is the first step in an iterative process. Further work will seek to validate and test these definitions and inform their evolution.

The Use of 99mTc-Mononuclear Leukocyte Scintigraphy for Necrotizing External Otitis Diagnosis

BACKGROUND

Necrotizing external otitis (NEO) is a severe infectious disease in the external acoustic meatus (EAM) and mastoid that may extend to the cranial base. Due to the lack of a gold standard examination technique, the diagnosis is often difficult and delayed. This study aimed to evaluate the sensitivity and specificity of 99mTc-mononuclear leukocyte scintigraphy associated with 99mTc-phytate in suspected NEO compared to 99mTc-MDP and 67Ga-citrate.

METHODS

A prospective study (32 patients) was conducted between 2011 and 2016.

RESULTS

At the end, twenty-four patients remained for the study conduction; nineteen had confirmed NEO diagnosis, one had sarcoma, one had EAM cholesteatoma, one had diffuse simple external otitis, and two had an inconclusive diagnosis. 99mTc-mononuclear leukocyte scintigraphy plus 99mTc-phytate was as sensitive as 99mTc-MDP bone scintigraphy (19/19X9/19), and more sensitive than 67Ga scintigraphy (19/19 x 17/19). Regarding specificity, it was superior to bone scintigraphy, 100% × 40% (5/5 × 2/5), and 67Ga scintigraphy, 100% × 20% (5/5 × 1/5). After the infection resolution, all NEO patients had their leukocyte scintigraphy negativized. To the best of our knowledge, this is the first study that evaluates this technique in patients with suspected NEO.

CONCLUSIONS

99mTc-mononuclear leukocyte was revealed to be the best option for NEO because of its specificity.

Dynamic Contrast-Enhanced MRI Parameters and Normalized ADC Values Could Aid Differentiation of Skull Base Osteomyelitis from Nasopharyngeal Cancer

BACKGROUND AND PURPOSE

The skull base osteomyelitis sometimes can be difficult to distinguish from nasopharyngeal cancer. This study aimed to investigate the differences between skull base osteomyelitis and nasopharyngeal cancer using dynamic contrast-enhanced MR imaging and normalized ADC values.

MATERIALS AND METHODS

This study included 8 and 12 patients with skull base osteomyelitis and nasopharyngeal cancer, respectively, who underwent dynamic contrast-enhanced MR imaging and DWI before primary treatment. Quantitative dynamic contrast-enhanced MR imaging parameters and ADC values of the ROIs were analyzed. Normalized ADC parameters were calculated by dividing the ROIs of the lesion by that of the spinal cord.

RESULTS

The rate transfer constant between extravascular extracellular space and blood plasma per minute (Kep) was significantly lower in patients with skull base osteomyelitis than in those with nasopharyngeal cancer (median, 0.43 versus 0.57; P = .04). The optimal cutoff value of Kep was 0.48 (area under the curve, 0.78; 95% CI, 0.55-1). The normalized mean ADC was significantly higher in patients with skull base osteomyelitis than in those with nasopharyngeal cancer (median, 1.90 versus 0.87; P < .001). The cutoff value of normalized mean ADC was 1.55 (area under the curve, 0.96; 95% CI, 0.87-1). The area under the curve of the combination of dynamic contrast-enhanced MR imaging parameters (Kep and extravascular extracellular space volume per unit tissue volume) was 0.89 (95% CI, 0.73-1), and the area under the curve of the combination of dynamic contrast-enhanced MR imaging parameters and normalized mean ADC value was 0.98 (95% CI, 0.93-1).

CONCLUSIONS

Quantitative dynamic contrast-enhanced MR imaging parameters and normalized ADC values may be useful in differentiating skull base osteomyelitis and nasopharyngeal cancer. The combination of dynamic contrast-enhanced MR imaging parameters and normalized ADC values outperformed each measure in isolation.

A Fatal Case of Meningitis Complicating Chronic Otitis Media and Base of Skull Osteomyelitis due to Carbapenemase (OXA-48)-Producing Klebsiella pneumoniae

Osteomyelitis of the base of the skull is a rare but life-threatening disease. Although Klebsiella pneumoniae is not a pathogen that is frequently associated with this infection, the clinical course can rapidly progress to meningitis. Here, we describe a case of chronic otitis media, secondary to OXA-48K. pneumoniae, which was complicated by osteomyelitis of the base of the skull and fatal meningitis.

Trends and Outcomes of Fungal Temporal Bone Osteomyelitis: A Scoping Review

INTRODUCTION

Temporal bone osteomyelitis is an invasive infection most often caused by bacteria and associated with high mortality. Fungal etiologies are rare and little is known of the predictors of disease severity and outcomes in fungal temporal bone osteomyelitis.

MATERIALS AND METHODS

A scoping review was performed to determine what is known from the literature on how clinical, diagnostic, and treatment characteristics relate to patient outcomes in fungal temporal bone osteomyelitis. Using PRISMA guidelines, three databases were searched to identify all published cases of fungal temporal bone osteomyelitis. Data were extracted from each study, including clinical, diagnostic, and treatment characteristics, and outcomes.

RESULTS

Sixty-eight studies comprising 74 individual cases of fungal temporal bone osteomyelitis were included. All studies were case reports. There were high rates of diabetes, facial nerve palsy, infectious complications, and need for surgical intervention, as well as a significant delay in the evaluation and diagnosis of fungal temporal bone osteomyelitis. Disease recovery was greater in patients presenting with otorrhea, comorbid diabetes, and in those without facial nerve palsy.

DISCUSSION

Many of the defining characteristics of fungal temporal bone osteomyelitis remain unknown, and future reports should focus on determining factors that improve timely diagnosis and treatment of fungal TBO in addition to identifying prognostic indicators for outcomes and survival.

Characteristics, management and outcome of a large necrotising otitis externa case series: need for standardised case definition

Background

Necrotising otitis externa is a severe ear infection for which there are no established diagnostic or treatment guidelines.

Method

This study described clinical characteristics, management and outcomes for patients managed as necrotising otitis externa cases at a UK tertiary referral centre.

Results

A total of 58 (63 per cent) patients were classified as definite necrotising otitis externa cases, 31 (34 per cent) as probable cases and 3 (3 per cent) as possible cases. Median duration of intravenous and oral antimicrobial therapy was 6.0 weeks (0.49–44.9 weeks). Six per cent of patients relapsed a median of 16.4 weeks (interquartile range, 23–121) after stopping antimicrobials. Twenty-eight per cent of cases had complex disease. These patients were older (p = 0.042), had a longer duration of symptoms prior to imaging (p < 0.0001) and higher C-reactive protein at diagnosis (p = 0.005). Despite longer courses of intravenous antimicrobials (23 vs 14 days; p = 0.032), complex cases were more likely to relapse (p = 0.016).

Conclusion

A standardised case-definition of necrotising otitis externa is needed to optimise diagnosis, management and research.

Emerging themes in necrotising otitis externa: a scoping review of the literature from 2011 to 2020 and recommendations for future research

OBJECTIVE

Necrotising otitis externa is an invasive, infective condition, with minimal evidence underpinning its diagnosis and management. This work aimed to analyse literature from the past decade, to identify emerging themes and important topics for future research.

METHODS

A robust literature search and review were conducted by two researchers. Sixty studies were filtered into the final review. A grounded theory approach was used to identify core themes. Data within these themes formed the basis of the review.

RESULTS

There is no consensus regarding a clinical definition or outcome measures of necrotising otitis externa, and there exists no level 1, 2 or 3 evidence to diagnose, investigate, monitor or treat necrotising otitis externa. Emerging themes in the literature direct researchers to important topics for future clinical trials, including risk factors, microbiological culture, management strategies and radiology.

CONCLUSION

In order to optimise understanding and management of necrotising otitis externa, future research requires robust clinical trials and consistently reported outcome measures.

A Rare Case of Streptococcus Pneumoniae Causing Malignant Otitis Externa Complicated by Skull Base Osteomyelitis

Skull base osteomyelitis is an aggressive infection involving bones of the skull. It is a rare complication of malignant otitis externa, caused by the contiguous spread of the infection. Patients are mostly elderly with comorbidities that compromise immunity. It is atypical for Streptococcus species to be encountered in basilar skull osteomyelitis. Here we present the case of an 80-year-old male with multiple comorbidities including diabetes mellitus with a two-month history of right ear pain associated with occasional discharge and diminished hearing who was found to have bacteremia and basilar skull osteomyelitis with Streptococcus pneumoniae isolated from blood and otorrhea fluid cultures. This unusual presentation of S. pneumoniae related skull base osteomyelitis could be attributed to an undiagnosed pancreatic cancer at the time of presentation. Malignant otitis externa can progress into invasive disease in the head and neck; almost all cases tend to be caused by Pseudomonas aeruginosa but unusual cases, such as this, can be caused by Streptococcus pneumoniae.

The association between radiological spreading pattern and clinical outcomes in necrotizing external otitis

Objectives

Methods

Results

Conclusion

Level of evidence

Otogenic Central Skull Base Osteomyelitis With Retropharyngeal Extension: A Case Report

Skull base osteomyelitis (SBO) is a life-threatening condition in patients with underlying comorbidities. Ear infections may spread through normal skull base fissures in this group of patients. However, its diagnosis is frequently delayed due to the unspecific clinical findings at onset, such as headache, with diverse cranial neuropathies later as the disease progresses. We present the case of a patient with otogenic skull base osteomyelitis complicated with retropharyngeal extension, treated with surgical drainage and broad-spectrum antibiotics directed toward extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli, with recurrence of the infection three months later. With this case study, we aim to stress the importance of antimicrobial resistance and how it can preclude an otherwise favorable prognosis.

Diagnostic approach to patients at risk of otogenic skull base osteomyelitis

BACKGROUND

Otogenic skull base osteomyelitis (OSBO) is rare and potentially fatal sequelae of otitis externa. Accurate and timely diagnosis is important due to rising incidence, morbidity and costs associated with treatment. Consensus on the diagnostic approach for OSBO has yet to be reached, in particular the utility of imaging modalities.

AIMS/OBJECTIVES

This study reviews a single institution's high-volume experience of OSBO, with the aim of analysing clinicopathologic features and imaging studies to develop a diagnostic algorithm.

MATERIAL AND METHODS

A retrospective review of patients admitted with OSBO from 2009 to 2019, was performed. After applying inclusion and exclusion criteria, 103 patients with 106 unique episodes of suspected OSBO were selected. De-identified information including patient demographics, clinicopathologic features and imaging outcomes was recorded and analysed.

RESULTS

HbA1c ≥ 7% significantly predicted for OSBO in univariate (OR 7.83, 95% CI 1.85-33.16, p = 0.01) and multivariate analyses (OR 5.21, 95% CI 1.05-25.81, p = 0.04). The CT/technetium-99m/gallium-67 combination produced better diagnostic accuracy for OSBO (AUROC 0.96, 95% CI 0.92-1), when compared to a CT/MRI combination (AUROC 0.86, 95% CI 0.79-0.93).

CONCLUSIONS AND SIGNIFICANCE

Once there is a clinical suspicion for OSBO, diagnosis is established by synthesising results from clinical assessment, pathologic investigations and imaging modalities. The imaging utilised to diagnose OSBO should vary according to the clinical situation and limitations of each modality.

A Case of Adult Clival Osteomyelitis

Clival osteomyelitis is a potentially life-threatening skull base infection. It is rare and generally challenging to diagnose and treat. Clival osteomyelitis is typically seen in the pediatric population and is very rare in the adult population. It occurs as a complication of recurring paranasal infections and malignant otitis externa. The exact pathophysiology of osteomyelitis of the clivus is relatively uncertain. Here, we describe a case of a 36-year-old man with medical history significant for hypertension and poorly controlled type 1 diabetes mellitus who experienced recurrent paranasal sinus infection for 2 years. He received multiple antibiotic treatments and underwent adenoidectomy without substantial improvement of symptoms. Ultimately, a diagnosis of the clival osteomyelitis through the help of a computed tomography (CT) scan of the paranasal sinus and neck was made. This diagnosis allowed for adequate intervention and treatment of our patient with subsequent resolution of his presenting symptoms. This case highlights the importance of high suspicion for clival osteomyelitis in patients with recurring sinus infections.

Necrotising Otitis Externa: A Review of Imaging Modalities

Necrotising Otitis Externa (NOE) has often posed some challenges in view of diagnosis and management by clinicians. One such challenge is the appropriate and timely use of imaging techniques since its use is critical not only in diagnosis but also in determining the extent and resolution of the disease. Hence, doctors in both primary and secondary health care need to be familiar with presenting symptoms while specialists need to be appraised of advances in imagining techniques in diagnosis and management of NOE. Whilst there is a general consensus amongst clinicians on some aspects of management of NOE, there is very limited consensus on the use of imaging modalities. There is no single modality of imaging that can provide a complete picture of diagnosis, disease progression and resolution. This review aims to highlight the strengths and weaknesses of various imaging techniques used in the diagnosis and management of NOE over the years and whether a multi-modal imaging technique at particular stages of the disease may provide better management outcomes.

Imaging of Acute and Chronic Skull Base Infection

Skull base infections are uncommon but can be life threatening without timely recognition. Imaging plays a crucial role because symptoms can be vague and nonlocalizing. Necrotizing otitis externa in diabetic or immunocompromised patients is the commonest cause of skull base osteomyelitis (SBO), followed by sinogenic infections and idiopathic central SBO. Multiparametric magnetic resonance (MR) and high-resolution CT are the mainstays for establishing a diagnosis and estimating disease extent, with MR being superior in ascertaining marrow and soft tissue involvement. Monitoring treatment response, of which imaging is a fundamental part, is challenging, with emerging promising imaging tools.

Skull base osteomyelitis imaging

PURPOSE OF REVIEW

Skull base osteomyelitis (SBO) is a challenging entity to diagnose and treat. The goal of this review is to summarize the imaging findings of SBO and present these in the context of recent studies on imaging of SBO.

RECENT FINDINGS

This review discusses the clinical presentation, pathophysiology and imaging appearances of SBO. The review further emphasizes the results of latest studies on imaging of SBO, and the role of different modalities in diagnosis and evaluation of disease course and treatment response. Brief discussion on differential diagnoses from an imaging standpoint is also included.

SUMMARY

Various imaging modalities play different and complimentary roles in diagnosis and management of SBO, which are discussed in this review.

Current management of skull base osteomyelitis

PURPOSE OF REVIEW

Skull base osteomyelitis (SBO) is a life-threatening condition. Due to an aging and increasingly multimorbid population, clinicians are more often challenged with this disease. Yet, there is no consensus on the optimal diagnostic and follow-up management. This review should aid clinicians in decision-making for their patients.

RECENT FINDINGS

Treatment-resistant otalgia or headache is suspicious of SBO. Pseudomonas aeruginosa remains the most common pathogen but clinicians are challenged with increasing rates of sterile or fungal cultures due to previously applied antibiotics/steroids. No single imaging modality is able to detect the full extent of the disease. Whereas functional nuclear imaging with gallium-67 or methylene diphosphonate-technetium-99m was once advocated, its actual benefit is questionable. Newer modalities such as fluoro-D-glucose-positron emission tomography (PET)/computed tomography, PET/magnetic resonance imaging (MRI), or diffusion-weighted MRI seem to be promising in diagnosis and follow-up. Finding the causative pathogen is of utmost importance followed by long-term intravenous antibiotics until the disease has completely resolved. Surgery plays a minor role in treatment but can be helpful in selected cases.

SUMMARY

The numerous challenges in SBO render management difficult, but with a clear work-up including regular clinical, laboratory and imaging examinations, outcome can be improved.

Incremental Role of 18F-FDG-Labeled Autologous Leukocyte PET/CT in Suspected Postoperative Recurrence of Skull Base Osteomyelitis

ABSTRACT

Skull base osteomyelitis is 1 of the complications of a middle ear infection seen mainly in immunocompromised individuals. A 3-phase bone scan and clinical, laboratory, and other radiological imaging are used for the diagnosis. However, in previously operated cases, bone scan findings are not reliable. We present a case of a 70-year-old man with persistent ear discharge postsurgery and with 3-phase bone scan negative for active infection. However, a subsequent 18F-FDG-labeled autologous leukocyte PET/CT study was able to diagnose the presence of active infection.

MRI of Emergent Intracranial Infections and Their Complications

Acute intracranial infections of the central nervous system and skull base are uncommon but time sensitive diagnoses that may present to the emergency department. As symptoms are frequently nonspecific or lack typical features of an infectious process, a high index of suspicion is required to confidently make the diagnosis, and imaging may not only serve as the first clue to an intracranial infection, but is often necessary to completely characterize the disease process and exclude any confounding conditions. Although computed tomography is typically the initial imaging modality for many of these patients, magnetic resonance imaging offers greater sensitivity and specificity in diagnosing intracranial infections, characterizing the full extent of infection, and identifying potential complications. The aim of this article is to serve as a review of the typical and most important imaging manifestations of these infections that can be encountered in the emergent setting.

Diagnosing necrotizing external otitis on CT and MRI: assessment of pattern of extension

BACKGROUND AND PURPOSE

Necrotizing external otitis (NEO) is a serious complication of external otitis. NEO can be classified according to-anterior, medial, posterior, intracranial, and contralateral-extension patterns. Currently there is no consensus on the optimal imaging modality for the identification of disease extension. This study compares NEO extension patterns on MR and CT to evaluate diagnostic comparability.

METHODS

Patients who received a CT and MR within a 3-month interval were retrospectively examined. Involvement of subsites and subsequent spreading patterns were assessed on both modalities by a radiologist in training and by a senior head and neck radiologist. The prevalence of extension patterns on CT and MR were calculated and compared.

RESULTS

All 21 included NEO cases showed an anterior extension pattern on CT and MR. Contrary to MR, medial extension was not recognized on CT in two out of six patients, and intracranial extension in five out of eight patients. The posterior extension pattern was not recognized on MR. Overall, single anterior extension pattern (62%) is more prevalent than multiple extension patterns (38%).

CONCLUSION

All anterior NEO extension pattern were identified on CT as well as MR. However, the medial and intracranial spreading patterns as seen on MR could only be identified on CT in a small number of patients. The posterior spreading pattern can be overlooked on MR. Thus, CT and MR are complimentary for the initial diagnosis and work-up of NEO as to correctly delineate disease extent through the skull base.